Pediatric emergency medicine trisk 3670 3670

anesthetic. When strips are used, they must be wet with either saline or topical
anesthetic before instillation. Otherwise, the strip itself may cause a corneal
abrasion. Examiners should be careful to instill just a touch of this dye to avoid
false positive readings. Fluorescein, which is orange, fluoresces yellow-green
when exposed to blue light. The examiner can view this fluorescence using the
blue filter on the direct ophthalmoscope or using a Wood or Burton lamp. If the
staining pattern reveals one or more vertical linear abrasions, the examiner should
suspect the presence of a retained foreign body under the upper eyelid. This
foreign body may be viewed and removed by upper eyelid eversion ( Fig. 114.2 ).

Perform Direct Ophthalmoscopy to Evaluate for Papilledema
or Retinal Hemorrhages
If either is noted, emergency consultation with ophthalmology is required.
Pharmacologic dilation of the pupil may be used to assist in evaluating the
posterior portion of the eye ( Table 114.2 ). Even so, this is a difficult procedure
to perform for most providers especially in children with eye injuries. If this
cannot be completed successfully, ensure that an attempt has been made to obtain
a red reflex (see “Check the Red Reflex” above).

Consider Bedside Ultrasound
Emerging evidence suggests that bedside ocular ultrasound can identify serious
injuries to the globe, particularly in patients who are unable to open the affected
eye. Papilledema, retinal detachment, vitreous hemorrhage, and lens dislocation
have been identified successfully. Of the applications, retinal detachment is the
best-established, with high sensitivity and specificity for identification. However,
bedside ultrasound is highly user-dependent, and experience affects performance
of the modality. Therefore, proper training and credentialing are necessary before
using bedside ultrasound clinically in the evaluation of ocular trauma.
TABLE 114.2
Emergency Department Ocular Dilating Regimen a
Phenylephrine

2.5%
Tropicamide 1%

For brown irides replace tropicamide with cyclopentolate
1%

a May

repeat regimen in 30 minutes if needed. Instilling proparacaine or tetracaine prior to these dilating
drops will enhance the dilation effect.

OPEN-GLOBE INJURY