Goals. Eye Exam Skills for Pediatric Providers: A Focus on Trauma. Eye Examina4on. General Tips for Kids Eyes. Eye Examina4on. Eye Examina4on 10/26/16

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1 Goals Eye Exam Skills for Pediatric Providers: A Focus on Trauma Gil Binenbaum MD MSCE The Children s Hospital of Philadelphia No financial conflicts of interest to disclose NOT a RH talk PracOcal Eye anatomy Eye exam Eye injuries Ocular Orbital General Tips for Kids Eyes DistracOon and speed Don t direct to look at things just show them Don t ask permission make noises, sing! Proparacaine can use mulople Omes MoOlity, pupils, red reflex, etc., first Then hold down if necessary Get everything ready But think of next examiner SedaOon, exam under anesthesia Inspect Acuity Red reflex MoOlity Eye Examina4on I-ARM ABNORMALITY OR ASYMMETRY Eye Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment ABNORMALITY OR ASYMMETRY Eye Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment ABNORMALITY OR ASYMMETRY 1

2 Ge]ng the eyes open InteresOng fixaoon target Gauze on eyelid skin Eyelid margins [Speculum with proparacaine] Getting the eyes open Eyelid margin Medial Canthus: Cornea (transparent) with iris behind Limbus (edge of the cornea) Upper Lid Lateral Canthus Eyelid margin ConjuncOva (transparent) & Sclera (white) Lower Lid 2

3 Fluorescein Fluorescein Blue light (vs UV) and magnificaoon MulOple uses: corneal abrasion, corneal laceraoon & ruptured globe, exposure keratopathy, etc. Slit lamp FOREHEAD ON BAR High-intensity light source focused to shine as a slit, in conjunction with a microscope can see anterior segment Cataract Corneal diseases Uveitis Infections Trauma Portable slit lamp 3

4 Cell (UveiOs, traumaoc irios) AlternaOve source of slit beam (and of a blue light) Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment ABNORMALITY OR ASYMMETRY Pupils Pupils Equal Round Reactive to Light And Accommodation 4

5 Round? Instead of PERRLA ReacOve to light? Right 4à2 Left 4à2 No APD (afferent pupillary defect) Need to check when focusing at distance, otherwise accommodating DDx is based on whether difference is greater in dark or in light 5

6 Pupils - Anisocoria Difference in pupil size Is difference greater in dark or light? DARK: Problem dilating (small pupil won t dilate) Horner Syndrome (ptosis, heterochromia) LIGHT: Problem constricting (large pupil won t constrict) Third nerve palsy (ptosis, XT, poor motility) Tonic pupil Pharmacologic (always ask if gotten eyedrops) Physiologic anisocoria Normal pupillary reactivity, usually < 1 mm difference Eyelids: MRD (margin-reflex distance) Ptosis: Horner syndrome (mild) vs 3 rd Nerve palsy (severe) MRI Head, neck, chest, +/- abdomen MRI brain, orbits Pupils - APD Afferent pupillary defect, or Relative afferent pupillary defect Optic nerve damage or bad retinal disease Not cataract, cornea, vitreous, functional disease Courtesy, Steve Galeka, MD Courtesy, Steve Galeka, MD Courtesy, Steve Galeka, MD 6

7 Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment Visual Acuity Best corrected acuity (glasses ON) Each eye separately Methods Snellen (20 / X ) 5 year old 20/40 or beker Count fingers Fix and Follow 2 months of age Light percepoon (light averse) Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment Red Reflex EXTREMELY USEFUL TEST EVERY KID Test both eyes together first Stand far enough away to look at both eyes Child can look right at you Turn dial on direct ophthalmoscope until in focus Examine reflexes Can then come in closer to look at each eye Refer any asymmetry (brightness, color, etc.) or abnormality 7

8 Leukocoria & Abnormal red reflex URGENT REFERRAL DDx Cataract Retinoblastoma Coats disease Retinal detachment Uveitis Infection PHPV Strabismus High refractive errors Etc Leukocoria & Abnormal red reflex TRAUMA RELATED DDx Corneal injury Hyphema Cataract Lens dislocation Vitreous hemorrhage Retinal detachment Extensive retinal hemorrhage (?) Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment Funduscopic Landmarks Optic Disc papilla Vascular arcades Macula Between arcades Central vision Fovea Center of macula, dark spot Greatest visual acuity Posterior pole Periphery Sides of eye NOT the back Near, mid, far Ora serata 8

9 Ophthalmoscopic Fundus Exam Tips for ophthalmoscopic exam (DIRECT ophthalmoscope) TIP 1: Maximize pupil size Dilate (tropicamide 1% shortest acong) Undilated: Fixate at distance, dim lights TIP 2: Need to be VERY CLOSE Harder to get close enough in kids Use child s head or shoulder to stabilize Can start inches from child but need to get closer Not close to close enough Ophthalmoscopic exam TIP 1: Large pupils TIP 2: Get close TIP 3: Approach 30 degrees from midline That is the angle of opoc nerve inseroon Keep child fixated ahead in distance Choose medium or large light size Look through ophthalmoscope to red reflex Turn dial to focus unol vessels are in view TIP 4: Keep in mind spot size for perspec4ve Field of View (spot size) Direct Ophthalmoscope 9

10 Indirect Ophthalmoscope Field of View (spot size) Indirect Ophthalmoscope 3D Direct ophthalmoscope 2D Field of View (spot size) Indirect Ophthalmoscope 3D Direct ophthalmoscope 2D Tip 5: Follow the arrows 10

11 Follow the arrows Ophthalmoscope TIPS 1. Large pupils 2. Get close 3. Approach at angle to aim for opoc disc 4. Know spot size 5. Follow arrows to disc 6. When tracking vessels never turn your wrist, always turn your whole body-arm-scopehead as one unit Blurred margins Vessel obscuraoon Disc elevaoon 11

12 PanopOc much beker 12

13 Prac4cal Fundus Exam Red Reflex Very useful test Direct ophthalmoscopy Most likely use is to look at opoc disc Not sufficient to rule out a reonal problem/ trauma Not sufficient for SCAN/re4nal hemorrhage exam Requires dilated, indirect exam Scleral depression Exam tool for visualizing far periphery 13

14 Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy Mo4lity and Alignment MoOlity (and Alignment) MoOlity Good fixaoon object (toy) Don t need to direct Alignment Hirshberg (corneal light reflex) Cover uncover test (each eye one at a Ome) D. C. D E. 14

15 MoOlity (and Alignment) Strabismus Esotropia eyes turning in towards each other Exotropia eyes turning out from each other Hypetropia Adults diplopia; children - suppress Comitant versus incomitant strabismus Incomitant: cranial nerve palsy, orbital lesion, myasthenia, thyroid eye disease, Duane s, etc. Head posioon Children and adults adapt to maintain binocularity Comitant esotropia (same in all direcoons) and head straight Comitant strabismus (simple exotropia, not a third nerve palsy) and head straight 15

16 Sixth Nerve Palsy Incomitant esotropia Fourth Nerve Palsy Third Nerve Palsy Involves Four Of Six Extraocular Muscles Levator (Lid Elevator) Pupil Ptosis Eye Down And Out Dilated Pupil (anisocoria worse in the light) à Emergent imaging 16

17 Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment ABNORMALITY OR ASYMMETRY 17

18 Open Globe Injury Full thickness wound in eyewall (cornea/sclera) Lacera4on caused by a sharp object, at impact site, outside-in mechanism Rupture caused by a blunt object, increase in IOP, break at weakest point, inside-out mechanism Red Flag Signs for Open Globe Injury Consider mechanism of trauma Obvious signs LaceraOon or rupture site, uvea protruding Other signs: Large subconjuncoval hemorrhage Flat or very deep anterior chamber Irregular or peaked pupil Hyphema, vitreous hemorrhage CT Scan: foreign body, shape of globe In kids, may not know extent of injuries unol OR Uvea Iris + Ciliary Body + Choroid 18

19 Flat anterior chamber 19

20 AlternaOve source of slit beam (and of a blue light) Subconjunctival hemorrhage (SCH) (these 2 photos aren t trauma) 20

21 Extensive SCH, peaked pupil Open Globe Injury Management Eye Patch is not an Eye Shield! STOP exam NO PRESSURE on eye SHIELD NPO, bed rest AVOID painful procedures Analgesia, ano-emeoc, anobioocs, tetanus Examine other eye (or not) SURGICAL EMERGENCY: to operaong room Eye Shield I-ARM 21

22 Hyphema Blood in the anterior chamber Blunt trauma, rule out other injuries (open globe) Grossly visible penlight Micro-hyphema slit lamp managed the same Immediate concern high pressure Permanent opoc nerve damage and vision loss Re-bleeds ouen the bigger problem, first 5 days Hyphema Management Prevent re-bleed Eye SHIELD Bedrest Elevate head Comfort (dim room, acetaminophen, no NSAID s) NPO Sickle cell tesong (all African-Americans) Ophth consult Rule out rupture, manage IOP Followed daily Admit based on age, compliance, IOP, suspected abuse 22

23 Corneal Abrasion Exam Rule out penetraong injury Topical anestheoc will aid exam But chronic use unsafe Proparacaine (tetracaine songs more) Fluorescein exam Linear abrasions: check everted upper & lower lids for foreign body Concerning signs Large, or central, or see a white spot Contact lens wearer Corneal Abrasion Management Topical anobioocs Ointment may be beker than drops Apply in the ED auer exam Pain control Ointment Topical pain not helped by opiates Tylenol or NSAIDS? Patch Follow-up Ophthalmology 0-2 days (0-1 days if red flags) Large, or central, or see a white spot 14 yr old, right eye pain Corneal abrasion 1 week ago Treated with Polysporin from ED hkp://openi.nlm.nih.gov/imgs/512/360/ / _kjo g001.png 23

24 Corneal Burn Treat like corneal abrasion Ophthalmology consult/follow up Tenon s, conjuncoval laceraoon Teenager, unclear Hx Photophobia, pain, tearing, redness 24

25 Trauma4c Iri4s Mechanism: blunt trauma PresentaOon: 1-2 days auer injury Photophobia Pain Tearing Exam: Anterior chamber cell is diagnosoc Blepharospasm Perilimbal injecoon (ciliary flush)/red eye Pain with near gaze and light Trauma4c Iri4s ED Management Rule out open globe (consult) Otherwise follow-up ophth within 24 hours Long-acOng cyclopegic (5% homatropine) Topical steroids (discuss with ophth) Steroid side effects: glaucoma, cataract PO NSAIDS Dark sunglasses Looking up Orbital Fractures Clinical findings: Globe injury rule out Step-off on orbital rim Numbness in infraorbital nerve distribuoon RED FLAGS: Muscle entrapment Strabismus/diplopia Vagal symptoms (oculocardiac reflex) Enophthalmos (eye recedes) 25

26 Orbital Fractures White-eyed blowout fracture Minimal external signs of trauma May have delayed presentaoon Trapdoor fracture Bones more elasoc, snap back, traps muscle Suspect if nausea, vomiong, pronounced oculocardiac reflex with eye movement Orbital Fractures Management ED CT Orbits FINE CUTS, AXIAL & CORONAL (plain films inadequate) AnObioOcs controversial cover sinus organisms Abnormal exam à consult Surgery Wait 7-10 days & reassess moolity, diplopia, globe ExcepOons: Oculocardiac reflex bradycardia, N/V White-eye orbital floor blow out fracture Muscle entrapment (early repair beker outcomes) Lane, Orbit, 2007 Jordan, Ophth Plas, 1998 Eyelid Lacera4ons When to consult ophthalmology: Near canaliculus & lacrimal duct Crosses eyelid margin Pre-aponeuroOc fat in wound Levator muscle injury Full thickness wound Repair Eyelid skin 6-0 Fast Gut Deeper 5-0/6-0 Vicryl MagnificaOon Always give anobioocs topical +/- systemic 26

27 Tear duct involved Requires special repair 27

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29 3 week old You no4ce an abnormal red reflex Cataract Lens opacity #1 cause of blindness in the world Treat surgically Teenagers, adults - elective Amblyogenic-aged children (<7), need Rx Trauma, steroids, inflammation Newborns, relative emergency Operate by 4-6 weeks age 29

30 Cataract Congenital 1/3 inherited (examine parents) 1/3 systemic/syndromic 1/3 idiopathic Galactosemia, Wilson disease, diabetes, fetal alcohol Myotonic dystrophy Rubella, HSV, VZV, EBV, toxoplasmosis, syphilis Trisomy 21, Turner, neurofibromatosis, Lowe, Marfan Trauma UveiOs Steroids Another abnormal red reflex 30

31 ReOnal detachments TracOonal Usually abnormal blood vessels pull reona ReOnopathy of Prematurity Acute disease occurring PMA 30-45, later is scarring DiabeOc reonopathy (adults, not kids) Rhegmatogenous ReOnal tear, vitreous gets underneath Trauma High myopia History of severe ROP as infant, lifelong RD risk 31

32 ReOnal tear or detachment Painless Flashing lights New floaters If just a tear, then vision soll good on exam If detached, part or all of vision poor Curtain pulled down in front of my eye Abnormal red reflex Strabismus Diagnose with dilated fundus exam ANY VISION LOSS, ABNORMAL RR, STRABISMUS REQUIRES OPHTHALMOLOGIST EXAM Physical Examina4on I-ARM Inspect Anterior Anatomy and Pupils Acuity Red reflex and Posterior Anatomy MoOlity and Alignment ABNORMALITY OR ASYMMETRY Thank you 32