Any patient with a fluorescein-staining corneal defect who has a history of ocular herpes or who wears contact lenses should be referred urgently for ophthalmology consultation Fluorescein should not be instilled while patients have their soft contact lens in place as this may result in permanent discoloration of the contact lens Also, judicious use of fluorescein is important; too much will flood the ocular surface and may lead to false positive findings Patients who wear contact lenses should never be patched for abrasions even if the contact lens has been removed Patching the eye of a patient who often wears contact lenses may create a microenvironment that predisposes to bacterial ulceration of the cornea The contact lenses should be removed immediately and not worn until the cornea is healed and topical antipseudomonal topical antibiotics should be prescribed HYPHEMA CLINICAL PEARLS AND PITFALLS Patients with hyphemas obscuring the pupil require emergent ophthalmology consultation; all others require urgent ophthalmologic evaluation (within 24 hours) Patients with hyphema are at risk of increased intraocular pressure and rebleed Patients with sickle cell anemia are at particularly high risk for optic nerve compromise from elevated intraocular pressure; ophthalmology consultation should be prompt Current Evidence Hyphema can result from either blunt or penetrating trauma to the globe Traumatic forces result in shearing of vessels of the iris or ciliary body In most patients, bleeding stops quickly as the space is limited, and clotting seals the vessel These patients should be treated as an open-globe injury as described above, with shielding of the eye and emergent consultation with an ophthalmologist Patients with clotting disorders and those who take plateletinhibiting medications may be predisposed to hyphema or subsequent spontaneous rebleeding Patients with sickle cell disease or trait are at risk of increased intraocular pressures and rebleeding Current evidence does not support the routine use of antifibrinolytics in the treatment of hyphema Goals of Treatment The goals of treatment in the ED are as follows: (1) prompt recognition, (2) assessment of the level of urgency of definitive ophthalmologic management, and (3) emergent consultation with ophthalmology if there is a concern for elevated pressure, severe pain, hyphema covering the pupil, sickle cell disease, or visual acuity diminished past 20/200 Clinical Considerations Clinical Recognition The presence of blood between the cornea and the iris is a sign of severe ocular trauma Although the entire anterior chamber may be filled with blood, clots may also be small, requiring careful inspection for detection ( Fig 114.10 ) Sometimes the blood is more diffuse throughout the anterior chamber or may even be microscopic, requiring slit-lamp examination for detection (microhyphema) Patients with hyphema are vulnerable to spontaneous rebleeding for the first days after injury Patients with sickle cell anemia are at particular risk for ocular complications of hyphema FIGURE 114.10 Hyphema This 7-year-old girl was struck by a hard rubber ball and presented with blurred vision The 1-mm hyphema was only visible when she was upright (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004:403.) Triage Considerations Patients with severe eye injury and pain should be triaged and evaluated emergently Management An ophthalmologist must evaluate most patients with hyphema urgently and some emergently Telephone consultation is warranted for low-risk patients, though they may be followed serially in the ophthalmologist’s office as outpatients A low-risk patient is verbal, otherwise healthy, lacks hematologic comorbidities, does not have other concomitant injuries, has minimal pain, has a visual acuity better than 20/80, and has a small hyphema with layering below the pupil For others, emergent ophthalmic evaluation is recommended but should be tailored based on conversation between the emergency and ophthalmology physicians The eye trauma itself may result in some degree of physiologic sedation The eye should be shielded, not patched, and the patient should be placed on couch rest to the extent possible, and sleep with the head elevated by 30 to 45 degrees This position helps allow blood within the anterior chamber to settle inferiorly, thus allowing clearance of the pupillary axis, improvement of vision, and a better view for the ophthalmologist’s examination of the posterior segment of the globe Topical corticosteroids are helpful in most cases; they may help stabilize the clot (preventing fibrinolysis) and decrease inflammation, and thus an agent such as prednisolone acetate 1% given four times daily may be warranted at presentation with close ophthalmology follow-up Data supporting the use of these agents and of oral antifibrinolytics are limited despite this approach being commonly used Cycloplegic eye drops such as cyclopentolate 1% or atropine 1% twice daily may have benefit in pain control, allow improved evaluation of the posterior segment of the eye, and may provide better drainage of the anterior chamber, although there is not clear evidence TRAUMATIC IRITIS Clinical Manifestations Inflammation within the anterior chamber of the eye often presents 24 to 72 hours after blunt trauma The patient may complain of eye pain, redness, photophobia, and visual loss The pupil on the affected side may be constricted (see Chapter 29 Eye: Unequal Pupils ) Conjunctival injection may be confined to a ring of redness surrounding the cornea (ciliary flush) Definitive recognition of traumatic iritis requires slit-lamp examination Ophthalmology consultation is recommended when the diagnosis of traumatic iritis is suspected, as it is often associated with other ocular injuries Management Dilating drops and topical steroids are the mainstay of treatment for traumatic iritis Because of the risks associated with their use, these therapies should only be prescribed in conjunction with ophthalmology consultation FIGURE 114.11 Retinal hemorrhages in abusive head injury A: Retinal hemorrhages as seen using the narrow view from a direct ophthalmoscope B: Retinal hemorrhages as seen using a wide-angle ophthalmoscope or retinal photography (Reprinted with permission from Gold DH, Weingeist TA Color Atlas of the Eye in Systemic Disease Baltimore, MD: Lippincott Williams & Wilkins; 2001.) Traumatic Versus Nonorganic Visual Loss Occasionally, the emergency physician is faced with a child who is feigning visual loss Nonorganic visual loss can also be idiopathic and transient, or associated with stress A full ophthalmologic examination with visual acuity testing, pupil function, visual fields, and anterior and posterior segment evaluation is required before considering nonorganic vision loss In the absence of other signs of ocular or head trauma, this diagnosis should be considered It may become necessary to “trick” the child into demonstrating that he or she can actually see Patients who are truly acutely blind should demonstrate some degree of anxiety and virtually complete inability to navigate in new surroundings When asked to write their names on a piece of paper, truly blind patients can so accurately, unlike children who are functionally blind who assume they are unable to write Children who are feigning visual loss but not complete blindness ... was upright (Reprinted with permission from Fleisher GR, Ludwig S, Baskin MN Atlas of Pediatric Emergency Medicine Philadelphia, PA: Lippincott Williams & Wilkins; 2004:403.) Triage Considerations... emergent ophthalmic evaluation is recommended but should be tailored based on conversation between the emergency and ophthalmology physicians The eye trauma itself may result in some degree of physiologic... Lippincott Williams & Wilkins; 2001.) Traumatic Versus Nonorganic Visual Loss Occasionally, the emergency physician is faced with a child who is feigning visual loss Nonorganic visual loss can