common eye emergencies in pediatric age group

1. Done by : DR.Fawaz Alzweimel
Ophthalmology specialist/VR surgery fellow
Department of ophthalmology
The royal medical services

2. Epidemiology of Eye Injuries
A preventable causes of visual impairment in the WORLD.
Up to 40% of all ocular injuries occur in persons less than 17 years old.
Eye injuries are the leading cause of visual disability and noncongenital
unilateral blindness in children.
Very commonly, eye injuries occur during sports and recreational events .
the home has become the more common place for pediatric eye injuries.
Males account for almost 70% of all ocular injuries.
Boys between 11 and 15 years are the most vulnerable… 4 to 1 ratio
compared to girls.

7. Approach to eye exam
The history
Details, Mechanism and timing of injury…………… Where, When, How, and
With what?
 Change in vision
Flashes, floaters, curtain/shadow
Symptoms- pain, vision loss, double vision, photophobia symptoms etc.
Possibility of intraocular/intraorbital foreign body.

8. The Eye Exam
Visual Acuity “The vital sign of the eyes”.
External anatomy exam:
Looking for trauma, foreign bodies, lids and conjunctiva, dystopia,
proptosis, enopthalmos (deviations from normal anatomy).
Pupillary response “Equal, round and reactive to light”.
Visual fields.
Extraocular movements…. Limitation in any gaze.
Fundoscopic exam: evaluation of the retina, blood vessels and
optic nerve.
Intraocular pressure.
If Chemical burns, proceed to provide copious
irrigation before history and physical exam is done.

9. Plain x-ray…. To look for orbital wall
fractures.
CT- scanning….. To look for intraocular
foreign bodies.
MRI….. Contraindicated if metallic
intraocular foreign body is suspected.

10. A. Eye trauma…. Blunt vs. sharp.
B. Chemical burns.
C. Infections.

11. 1)Eye lid laceration
Superficial or deep.
Special care to that involving lid margin and the tarsal
plate, the levator muscle that lead to ptosis and the
canaliculai (the medial canthus). the later need tubing
technique to prevent epiphora after healing..
Check for associated foreign body or globe injury.
Treatment:
•Primary closure.
•Delayed closure after 12-24 hours if human bite or contaminated
wound.
•Tetanus prophylaxis.

13. 2) Subconjunctival hemorrhage:
Treat with cool compresses and artificial tears if
symptomatic.
Avoid ASA/NSAIDS, heavy lifting, strenuous activity.
It takes 1 to 2 weeks to resolve.

14. Symptoms:
pain, tearing, photophobia, blepharospasm and FB
sensation.
Evert the upper lid to look for hidden foreign bodies.
Treatment:
•Topical anesthesia then removed by cotton tip or needle
under the microscope by an ophthalmologist.
•topical antibiotic drops or ointment.
Avoid patching in children….. Amblyopia.

16. It is an Epithelial defect due to the trauma, Accompanied by
pain, foreign body sensation, tearing, blepharospasm and
decreased vision.
 Dramatic response with instillation of topical anesthetic.
The ulcer could be sterile or infected.
Evert the upper lid as a foreign body is the cause.
Treatment:
Lubricants ……..enhance healing
Topical antibiotics…… treat/prevent secondary infection
Cycloplegics…….relieve pain.

19. Orbital wall anatomy
The medial wall: 4 bones ( Maxillary, Frontal, Ethmoid and
Lacrimal bones).
The lateral wall: 2 bones (Sphenoid and Zygomatic bones).
The roof: 2 bones (Frontal and Sphenoid bones).
The floor: 3 bones ( Maxillary, Zygomatic and palatine bines)

20. orbital floor fractures
“Blow out Fracture”
The most common as the floor is the weakest part ( the roof
of maxillary sinus).
Usually due to blunt trauma.
Symptoms and signs:
Eye lid swelling, diplopia, restricted eye movement especial
upward, enopthalmos, hypoesthesia over the cheek.

21. Management
Imaging study: plain x-ray or CT-scan.
Observation with:
Tetanus prophylaxis.
Prophylactic Antibiotics with Broad spectrum antibiotic (Keflex,
Augmentin) for 10-14 days, are controversial.
Nasal decongestants BID for 10-14 days.
No nose blowing.
Ice pack 24-48 hours.
Go for surgery only if:
Entrapped muscle, Oculocardiac reflex (Heart rate decreases
with eye movement), facial hypoesthesia, symptomatic diplopia with
minimal improvement over time or large floor fracture leading to
enophthalmos.
Surgery is most commonly performed (if indicated) after 1 to 2 weeks
if indicated.

23. 6) Hyphemas
Defined as Blood in the Anterior Chamber.
Usually a result of blunt, projectile or penetrating trauma. But can
be spontaneous as in juvenile xanthogranuloma.
Commonly in the Pediatric population.
Signs/Symptoms:
Pain, Decreased vision and irregular pupil.
Clinical grading from grad 1 to grade 4.
Complications:
1. Secondary Hemorrhage (Rebleeding). High risk In the first 5 days
and high rate in young child and sever hyphemas.
2. Corneal blood staining.
3. Anterior/Posterior Synechiae.
4. Optic Atrophy.
Prognosis/Outcomes:
The lower the grade of hyphema the better the prognosis.

24. Management of hyphema
Hospitalization vs. Outpatient Bed rest:
Risk of Rebleeding?
Grade of Hyphema (Grade 2 or higher)
IOP at time of presentation (>30mm Hg)
Elevate the head of the bed 30-45º.
Eye shield.
Pain control (Avoid antiplatelet effects of certain NSAIDS).
Topical Cycloplegics(Atropine/ Tropicamide):
Reduce ciliary muscle spasms and Dilate the iris.
Topical vs. Systemic AMICAR (Aminocaproic acid):
Antifibrinolytic.
Prevention of normally occurring clot lysis allows blood vessels time to
repair.
May need IOP lowering agents.
Topical vs. Systemic Steroids:
Decreases the associated iritis and development of synechiae.

26. Can result in rapid elevation of orbital pressure because the orbit is a relatively
closed compartment.
Untreated, orbital compartment syndrome may result in optic nerve ischemia
and irreversible vision loss in less than90 minutes.
Spontaneous vs. traumatic.
Signs and Symptoms:
Pain, decrease vision, diplopia, Globe proptosis , Lid ecchymosis and tightness,
Subconjunctival hemorrhage with chemosis, Limited EOMs, Increased IOP,
Diminished VA and pupil responses (+RAPD).
Treatment:
Emergent lateral canthotomy and cantholysis.
7) Retrobulbar Hemorrhage

28. 8) Iridodialysis
Separation of the iris from it is root due to blunt trauma.

29. 9) Ectopia Lentis
Displacement of the lens from it is normal position

30. 10)Optic Nerve Avulsion
Partial or complete avulsion.
As a result of trauma that lead to sudden extreme rotation of the globe or a
sudden anterior displacement of the globe.

31. 11)Retinal detachment
Immediately post-trauma or may be delayed up to several months.

32. 12) Rupture globe
 A full thickness laceration of the globe as a result of trauma that may be with
blunt, penetrating or perforating objects.
 Can be corneal, scleral or combined (corneoscleral).
 Symptom: PAIN, greatly decreased vision, diplopia.
 Signs: Low IOP, Teardrop pupil, prolapsed iris, hyphema, hyphema with
normal or low IOP, 360 degree Subconjunctival hemorrhage.
 Management:
If suspected rupture Minimize manipulation of the globe and apply a Protective
eye shield.
CT orbit and brain, axial and coronals with 3 mm cuts and Evaluate for
intraocular foreign body.
NPO.
IV antibiotics –cefazolin and gentamycin in children.
 Antiemetic/pain medications.
Surgical repair.
 5-10% of penetrating injuries at risk for endophthalmitis, which leads to vision loss.

34. Begin irrigation immediately, even before completing the history.
Alkali burns are worse than acid burns
Acid burns: ( coagulative necrosis) Denaturation of tissue proteins, act as
barrier to prevent further diffusion. Battery fluid and chemistry labs solutions.
Alkali burns: (liquefactive necrosis) Do not denature tissue proteins, tend to
penetrate deeper. Lye, cement cleaner, drain cleaner, fertilizer, sparklers, and
firecrackers produce alkaline burns because they contain sodium hydroxide.
Clinical findings:
Conjunctiva hyperemia or blanching ( the later has bad prognosis and indicate
sever ischemia), chemosis, corneal epithelial erosions, corneal haziness/edema,
Severe- corneal opacification, limbal ischemia.
Complications:
Corneal melting, severe corneal and conjunctival scarring, uveitis, glaucoma.
Ocular Chemical Burn

36. Management:
Immediate irrigation: with normal saline or lactated ringers for At least 30 minutes
until pH normalizes (may require up to 8-10 liters). Do before checking VA or fluorescein
staining, and Recheck pH 5 minutes after irrigation stopped.
After irrigation Check visual acuity, Fluorescein stain, IOP.
Treatment:
 Bacitracin or erythromycin ointment q 1-2 hours with cycloplegia (Atropine,
Scopolamine, Homatropine).
 May need IOP lowering or steroids.
Ocular Chemical Burn.. Cont,

37. Eye infections
A) Ophthalmia Neonatorum
Conjunctivitis within the 1st month of life.
Common causes:
Chlamydia trachomatis.
Staphylococcus aureus.
Streptococcus pneumoniae.
Neisseria gonorrhea.
Herpes simplex virus.
Signs/symptoms:
Purulent (gonococcal) or mucopurulent discharge, conj injection, eyelid edema, chemosis

38. Management:
Conjunctival scrapings for gram stain, giemsa stain.
chlamydia antibody test,
cultures (blood and chocolate agar).
Viral cultures or antibody tests.
Treatment:
With topical antibiotic eye drops and/or ointments, Guided by results of gram and
giemsa stains.
In Chlamydia trachomatis ; treat with systemic erythromycin (50mg/kg/day x 3
wks) since pneumonitis and otitis media can coexist with erythromycin ointment
4x/day.
Ophthalmia Neonatorum… cont,

39. Viral vs. bacterial infection.
Symptoms:
Bacterial:
Conjunctival injection with mucopurulent discharge.
Viral:
Watery or mucoid discharge and ipsilateral preauricular LAD.
Treatment:
Bacterial:
Topical antibiotics.
Exception is gonococcal which requires systemic antibiotics and topical drops.
Viral:
Supportive treatment with cold compresses and artificial tears.
Contagious for first 10 days.
B) Acute Conjunctivitis

40. Preseptal cellulitis VS. Orbital cellulitis
Common organisms:
Staphylococcus aureus, S. epidermidis,
Streptococcus pyogenes, Haemophilus influenzae.
Preseptal cellulitis:
Involves soft tissue of eyelids and periorbital tissues anterior to the orbital
septum.
Patient presents with erythema, swelling, tenderness of eyelids and
surrounding periorbital area.
Orbital cellulitis:
More serious infection involving extension of the infection posterior to the
orbital septum and into the orbit.
At risk for cavernous sinus thrombosis, meningitis and brain abscesses.
Proptosis, ophthalmoplegia, decreased vision, significant pain on eye
movements, abnormal Pupillary reflexes.
C) Cellulitis

42. Mild preseptal cellulitis:
Oral antibiotics.
Severe preseptal or orbital cellulitis:
Admit patient and start systemic broad spectrum antibiotics until
infectious agent is identified.
Can add topical antibiotic ointment.
ENT consultation if sinusitis or mucocele present.
If patient is immunocompromised; consider mucormycosis
(severe fungal infection) with Black eschar sign in the nose or
roof of mouth.
Immediate surgical debridement and antifungal treatment.
Treatment of Cellulitis:

43. Please…………………
When you are playing games like basketball, tennis, squash,
baseball and projectiles (including toys, guns, darts, stones, air
guns, paintballs, and BB guns), wear a safety glasses. Eye injuries
are common in children playing these sports without any safety
glasses.

44. Thank you