Pediatric emergency medicine trisk 1014

penetration. Alkaline substances tend to cause more damage as they cause
saponification of fatty acids and can essentially “melt” the cornea and gain access
to the internal structures of the eye.
Goals of Treatment
Chemical injury to the eyeball is a true ocular emergency requiring immediate
assessment and intervention by ED personnel. Copious irrigation, even prior to
ocular examination in many cases, is necessary to minimize damage to the ocular
surface and is the mainstay of treatment if exposure is suspected. Emergency
management may be the most important factor in determining long-term visual
outcome.
Clinical Considerations
Clinical Recognition. Often, there is a clear history of a noxious substance
coming in contact with the ocular surface. It may also be that the event is not
witnessed and a parent may not be certain of the caustic exposure. Thus, the ED
clinician must maintain a high index of suspicion in children presenting with
photophobia or an irritated, red or painful eye of acute onset. A prompt pH test
done by touching a litmus strip to the eye can be useful in detecting acidic or
alkaline conditions. It is also important to determine whether particulate matter
may have been deposited on the ocular surface. Smoke can cause chemical
conjunctivitis, particularly in housefires when chemicals are liberated into the air
from burning plastics and other substances. Foreign bodies such as ashes and
other particulate matter in smoke are not uncommon. The examiner must also
assess the degree of exposure. If a child has no symptoms (e.g., pain,
photophobia) or signs (e.g., red eye, epiphora, conjunctival swelling) and a weak
history of actual chemical exposure to the eye it may be acceptable to avoid
lavage.
Clinical Assessment. A thorough clinical examination of the eye is often deferred
until after irrigation if there is confirmation, or strong suspicion of, chemical
exposure. Immediate intervention is essential to improving the patient’s
prognosis.
Management. Any patient with sufficient history should be immediately placed in

the supine position so ocular lavage may be started. This procedure can often be
frightening and anxiety provoking for a child, and some level of restraint is often
needed. Sedation and topical anesthetic may be helpful, but the physician should


not delay lavage while waiting for either of these adjunctive therapies. Usually,
the irrigating solution itself will induce cold anesthesia. If active manual
irrigation is performed, the eyelids must be retracted for maximal exposure of the
cornea and conjunctiva. A speculum or Desmarres retractor may be used to help
obtain optimal exposure.
A typical eye irrigation setup includes an IV pole and a 1 L normal saline IV
bag attached to a tubing set without a needle on the end. While the provider holds
the distal end of the tubing over the patient’s eye the irrigation solution is allowed
to flow, with the system at its maximum flow rate, across the surface of the open
eye from medial to lateral. If both eyes have been exposed, a set of nasal cannula
prongs can be attached to the IV tubing and then the prongs can be taped over the
patient’s nasal bridge (each prong directed at the medial aspect one eye). Both
eyes can then be easily lavaged simultaneously. The Morgan Lens is a
commercially available sterile plastic device that resembles a contact lens. It fits
over the eye and can be connected to tubing that allows for continuous flow of
fluid on to the ocular surface ( Fig. 123.12 ). It is quick and easy to set up and
provides a “hands-free” method of irrigating the cornea and conjunctiva. A
mechanism to collect excess fluid (such as towels, suction, basins, etc.) should be
in place. Virtually any IV fluid can be used for ocular lavage, although normal
saline solution is most commonly used. The use of more pH neutral solutions
(Ringer’s lactate, NS with bicarbonate buffer, or a balanced salt solution) may
decrease ocular discomfort and irritation associated with irrigation. Regardless of
the method used, lavage should be continued until the involved eye(s) has
received either 2 L of fluid or until approximately 20 minutes have elapsed. Lid
eversion should be performed (see Chapter 114 Ocular Trauma , Fig. 114.2 ), and

lavage should be continued with the lid in this position so that the conjunctiva
under the upper lid may also be cleansed. Mechanical debridement should be
limited to the removal of visible particles from the ocular surface, which may
contain small amounts of the offending agent or necrotic debris.
After irrigation is performed as described above, the pH should be remeasured
every 15 to 30 minutes to determine whether it has normalized (pH 6.5 to 7.5)
and is equal between the two eyes. The end point of equality should only be used
if one eye has not been exposed to caustic chemicals. The conjunctiva under the
upper lid may also be tested separately because noxious material can be harbored
in the recess above the eye under the lid. Irrigation should continue until
normalization of pH has been achieved.


FIGURE 123.12 Irrigation setup for ocular lavage (A ) and the Morgan Lens (B ).

Ophthalmology consultation is indicated in cases of significant chemical injury.
Waiting for the consultant should not delay irrigation and the ophthalmologist
should be notified while lavage is ongoing. In cases of very minor exposure to
substances that are clearly neither alkaline nor strongly acidic, and when the eye
is not injected, an ophthalmology consultation may be deferred. However, the ED
clinician should be cautious about the absence of conjunctival injection because
alkali burns can cause blanching of the conjunctiva, which is a poor prognostic
sign.

Hordeolums and Chalazions
A hordeolum is an acute infection of the eyelid that presents as a localized painful
swelling. Hordeola can be external (resulting from blockage of a gland of Zeis on
the lid margin; classic “stye”) or internal (resulting from blockage of a
meibomian gland). A chalazion, which also results from a blocked eyelid gland,
may initially present with some inflammation and tenderness, but typically

progresses to a painless localized eyelid swelling as the inflammation resolves.
Styes and chalazions are typically sterile but can progress to infection, most
commonly with staphylococcal species.


FIGURE 123.13 Acute stye (external hordeolum).

Both conditions may present acutely with localized lid swelling, erythema, and
tenderness. Styes are associated with swelling and purulent drainage at or near the
lid margin ( Fig. 123.13 ). More than one lesion may occur simultaneously, and
more than one lid may be involved. An acute chalazion causes swelling and
redness in the body of the eyelid and may be associated with drainage on the
conjunctival surface of the eyelid with or without a red eye. It may also drain via
the skin ( Fig. 123.14 ). A chalazion typically enters a chronic granulomatous
phase in which there is a nontender, noninflamed, mobile pea-sized nodule within
the body of the eyelid ( Fig. 123.15 ). History can be helpful in establishing these
diagnoses because patients often have had recurrent lesions in the same or other
eyelid.