5 eye emergencies you need to know about

| January 4, 2018
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Remember in high school biology class when it was frog dissection day? The weird formaldehyde smell, that rubbery lifeless creature— we all got through it, right? Everyone had differing levels of “ewwww” but somehow we completed the tenth grade. In my school the following year we had to dissect bull eyeballs, and I’m reporting today that I just haven’t gotten over the grotesque trauma. Picture it: fourteen 16-year old girls (all girls school) examining their own sample of enormous bovine eyeball. So weird. I’m blaming this singular activity on why, as a physician now with almost 20 years of experience I still try to play “nose goes” at work to find out who would go see the patient in Room 6 with the eye complaint. I’m also attributing this to the reason why I haven’t written about what I think you need to know about eye emergencies in kids.

Well, friends, I am conquering this phobia TODAY.  Right now.

I’m going to get pinkeye (also known as conjunctivitis-25-cent word) out of the way first.

I’m not labeling this as an eye emergency but this infectious/inflammatory process in the white part of the eye, known as the conjunctiva, can be extremely contagious and goes through classrooms like wildfire in the forest. It can be really tricky to tell whether or not the pinkeye has a viral (most of them) or bacterial cause, but if there is lots of green/yellow mucus coming out of one red eye only, then that suggests more of a bacterial cause to me and makes me more inclined to give antibiotic eye drops. Otherwise, supportive care with warm compresses, patience, and a doctor’s note about staying home until it resolves or the child is on drops for 24 hours are all that’s needed.

So let’s move on to some more serious eye emergencies about which it’s important to have some familiarity. Of note, we often refer to the eyeball as the “globe.” I actually like that term.

Chemical Burns

When the eye comes in contact with (most of the time via an accidental splash) a strong acid or alkaline substance, the delicate pH in the eye is disrupted, causing cell damage in as few as 5 minutes. People note eye pain and burning, decreased vision, red eyes due to irritation, and many times extreme difficulty even opening the eye.

The way that we help mitigate the direct cellular injury is by vigorous irrigation of the globe itself with pH neutral saline until the pH of the eye (that we test with those little paper strips- remember?…high school….) returns to a neutral range. There’s a special eyelid retractor that is used to help obtain maximum exposure in eye surface area of the irrigation fluid to wash away as much of the irritant as possible. It’s not uncommon that we wash out the eye for around 30 minutes or even longer until the appropriate pH is achieved.

What can you do about this?

  • Be really vigilant about keeping cleaning/gardening/automotive/other caustic substances away from plain view of kids. Alkaline substances tend to cause worse injury; just know this.
  • If anyone around you gets a splash, wash out the eye immediately with water. Yes, that means run water from the sink over an open eye the best you can. Do this for a few minutes, then get checked out in urgent/emergent care. Because, above.

Direct Eye Trauma

This seems to be happening more and more with the rise in paint ball-type activities in addition to traditional sports like baseball or tennis and even lacrosse. Direct trauma to the globe can result in fractures of the bones that frame the eye socket, which can then do bad things like entrap the nerves that move the eye itself. This needs immediate attention, as does a ruptured globe–which is when the entire integrity of the eye is disrupted and “contents” can appear to be leaking out. This needs immediate emergent evaluation. A blow to the eye can also cause bleeding into an enclosed anterior chamber of the eye. We call this a hyphema and it is a real emergency, because the blood that collects there can interfere with the pressure balance in the eye, and depending on the size of the blood collection, can cause permanent vision damage. Patients with a large enough hyphema need to be admitted to the hospital for frequent medication and pressure checks. Many of them are visible to the naked eye: when you look at the eye, it appears as though there’s a “layering” of fluid, kind of like water in a fish bowl.

Significant trauma, such as what happens in a car crash or child abuse, can result in bleeding or detachment of the retina. Rapid acceleration and subsequent deceleration cause this, and older patients describe some vision loss but also “flashes” of light and “floaters” or black dots that seem to move through their visual field. This is typically NOT a painful situation in the eye, but it does require emergent evaluation by an ophthalmologist.

What can you do about this?

  • Get evaluated immediately, and keep the head elevated at about a 30 degree angle so as not to increase the pressure in the eye.

 

Foreign Object in the Eye

Most of the time it’s fairly obvious when there’s a foreign body in a child’s eye–they shut their eye tightly without opening, describe that it’s painful or cry if they are not yet verbal, and have excessive tearing. The key in treatment here is to get the object OUT before it scratches the eye surface, causing a corneal abrasion. And this can be a challenge, especially in young kids in a lot of pain. There are special topical ophthalmic anesthetic drops that can help with this, and then after removing the object and irrigating the eye, a special fluorescent light and eye drop are used to determine if a corneal abrasion exists. If so, then antibiotic drops are prescribed so that the germs that live on the skin in the area don’t invade into deeper parts of the eye and cause more significant infection.

What can you do about this?

  1. Irrigate if you can, but then get seen by a medical professional.

Periorbital/Orbital Cellulitis

These fancy 25-cent words represent what happens when the usual germs that live on the skin (mostly face and nose) invade into the deeper layers of skin either around the eye (periorbital, with “peri”  meaning “around” and “orbital” meaning “eye”) or into the eye socket itself (orbital). So technically, this isn’t an eyeball emergency per-se but it’s common enough and close enough to the globe that I think it’s worth including here. Patients who have this disease typically have marked swelling of the upper and/or lower eyelids, red eyes, and some pain. Orbital cellulitis, more severe, causes a limitation of eye muscle movements, and this is often the hallmark of diagnosis. Depending on whether or not there is fever or other systemic involvement, sometimes oral antibiotics are all that’s needed for therapy if it’s a simple periorbital cellulitis, but occasionally a CT scan plus hospital admission with IV antibiotics is required.

What can you do about this?

  1. It can be difficult to tell the difference between periobital cellulitis and other problems- like a local allergic reaction to an insect bite- so if the redness and swelling around the eye persists after several hours and is NOT improving, a prompt evaluation really is necessary.

Eye tumors

Thankfully, eye tumors are quite rare, and nearly always require some type of imaging (usually CT scan) to make the diagnosis. What I want you to know here is that anytime there’s a change noted in the eye— color, one eye seems to “stick out” of the head or protrude more than the other or doesn’t seem to move in line with the other eye, then this needs to be investigated. As an example, clinicians who examine newborns are trained to look for the “red reflex” in the eye: when a light is shined into the eye, the pupil should look red and not white. When it’s white it increases the suspicion for a tumor called retinoblastoma, and those babies get prompt referral to pediatric ophthalmology and oncology.

What can you do about this?

  1. Just keep a close “eye” on your child, and don’t delay getting any changes checked out just because you think “it might be nothing.”

While this list is by no means comprehensive, I hope it helps expand your eye knowledge horizons. We take “eye stuff” very seriously in acute care medicine: we only have 2 and they are critical to our functioning, so any chance we have to heal an injury, treat an infection, and prevent an exposure we’ll take, no matter how badly it might give a few of us the heebie-jeebies.

Have YOU had an eye injury? Or your child? What was your experience like? Here at PM Pediatrics in Annapolis,  I welcome any and all stories, comments, and anecdotes.

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About the Author - Dr. Christina Johns, MD, MEd

Christina Johns, MD, MEd is the Senior Medical Advisor at PM Pediatrics. As a parent, pediatrician and pediatric emergency physician with a master’s in education, she shares her own expertise, plus the wealth of knowledge from our highly skilled staff, with patients and families everywhere.

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