PEMPix is the American Academy of Pediatrics Section on Emergency Medicine’s annual visual diagnosis competition. This year, in addition to the 10 finalists I will be presenting (virtually) at the National Conference and Exhibition I will be sharing three cases online in advance of the conference. This is the second of the three cases.

This case was submitted by…

A 5-year-old otherwise healthy male patient presented to the Emergency Department with trauma to his left eye. He was playing with his brother who kicked a ball into a window that the patient was standing next to. The ball shattered the window and glass flew into the patient’s face. The mother, who did not witness the event, noticed dried blood over the patient’s face and eyes and immediately brought him to the Pediatric ED. On arrival the patient’s vitals were normal and there was no active bleeding.

Eye Exam

Visual Acuity Grossly intact in both eyes. The injured left eye was positive for hand motion and finger counting at 3 ft only        

Pupils PERRL, no definite afferent pupillary defect

Eye Motility Able to track with full and conjugate extraocular eye movements in both eyes

A. Hyphema

B. Hypopyon

C. Corneal laceration with uveal prolapse 

D. Vitreous hemorrhage 

E. Corneal foreign body 

C. Corneal laceration with uveal prolapse

This patient was found to have a full-thickness corneal laceration with uveal prolapse of the left cornea. A corneal laceration can be either a partial or full thickness injury to the cornea usually caused by trauma with a sharp object, the glass in this case. It requires immediate Ophthalmology consult and surgical repair.

The patient was given a dose of morphine, Zofran, and tetracaine ophthalmic solution. Ah eye shield was also applied.  A bedside ultrasound was performed and showed no obvious deformities followed by a CT scan which confirmed no globe deflation or foreign bodies present.  Ophthalmology was consulted and took the patient to the operating room and repaired both a corneal and scleral laceration. While on the floor he received IV antibiotic therapy, ampicillin/sulbactam, antibiotic eye drops, and steroid eye drops. He was observed for 48 hours without any signs of infection and cleared for discharge with close ophthalmology follow up.

A Hyphema is a pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris) and is unlikely in this case as the defect appears outside on the surface of the cornea. A Hypopyon is a pooling or collection of white blood cells or other inflammatory cells in the anterior chamber of the eye and is not seen in the picture above. Vitreous hemorrhage is defined as the presence of blood within the vitreous cavity, which is the space lined posteriorly by the retina and anteriorly by the ciliary body and lens. The substance seen on the surface of the cornea in the picture above is not a Corneal Foreign Body but actually iris extruding from a corneal laceration. In addition, a CT scan of the orbits was obtained in this case which did not show any foreign bodies present.

References

Willmann D, Fu L, Melanson SW. Corneal Injury. [Updated 2021 Jul 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459283/