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Mysterious Eye Trauma: Diagnosis and Investigation

Detailed medical record of a 13-year-old boy's emergency visit after being hit in the eye, with assessment of injuries and possible child abuse concerns. Includes patient and mother's conflicting reports, exam findings, and treatment plans.

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Mysterious Eye Trauma: Diagnosis and Investigation

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  1. More Than Meets The Eye

  2. Visit 1: 11/18/02 • 13 year old AA male presents to UEC for emergency visit • CC: “I got hit in the eye with a stick this morning” • Occurred at approximately 5:30 a.m. • Ice used to reduce swelling

  3. Visit 1: 11/18/02 • Child is accompanied by his mother and the school language program coordinator • Mother speaks Spanish and VERY limited English • Child speaks English and Spanish

  4. Laterality: OD + redness OD + pain (4/10) + photophobia OU + flashes, only when hit (-) tearing (-) diplopia (-) meds (-) allergies HPI

  5. Hmmm... • Who hit the patient? • Where did the incident occur: at home, on the way to school, at school? • Did anyone witness the incident? • Who made the appointment?

  6. Exam Findings • Patient has never worn glasses • Vision is 20/50- OD, 20/60 OS without correction • With pinhole, improves to 20/20- OD • PERRLA(-)MG

  7. OD + lid edema +1 diffuse injection + SPK;visible iris pigment on corneal endothelium OS Clear lids and lashes Clear conj. Clear cornea SLE

  8. SLE • + cell and flare in the anterior chamber OD (~20 small cells) • Gonioscopy: Trabecular meshwork visible in nasal, temporal, and superior quadrants; Ciliary body visible in inferior quadrant • Possible heme with recessed angles inferiorly and nasally

  9. Other findings • IOP: 17 OD, 18 OS at 3:55 p.m. using Tonopen • Observation: A distinct contusion runs diagonally across the eye from the nasal superior lid to the temporal inferior lid

  10. Anything mysterious? • Would a stick make a diagonal bruise across the eye? • OR • Would the object have to be smaller (approximately the size of the orbit)? • What other object could have caused such a bruise?

  11. OD 0.3/0.3 CD, flat, pink, distinct margins +FLR, clear macula Evenly pigmented background OS 0.3/0.3 CD, flat, pink, distinct margins +FLR, clear macula Evenly pigmented background DFE

  12. Peripheral Retina OD

  13. Peripheral Retina OD • Attached retina 360 degrees • (-) vasculopathy • (-) hemes • White without pressure • Uniform, white, iridescent, edematous band from 3 to 10 o’clock; flat vessels course over the band • 3 small holes found at 8 o’clock, confirmed with scleral depression

  14. Diagnosis? • Commotio Retinae OD

  15. Missing pieces • Who hit the patient? • Where did the incident occur: at home, on the way to school, at school? • Did anyone witness the incident? • Who made the appointment?

  16. He says/She says • Patient says that mother’s boyfriend or a friend of the boyfriend hit him • When coaxed, admits that he was hit with a fist • Patient reports that boyfriend has been living in mother’s house for 5-6 months

  17. He Says/She Says • Mother admits that her boyfriend hit her son • Reports that boyfriend has been living in her home for one month • Does not give any information on whether a stick or fist was used

  18. Additional info • Child reports being hit at approximately 5:30 a.m. • After being hit, the child went to school • School principal called Social Services • Social Services arrived at school and made the appointment at UEC

  19. Assessment? • 1) Traumatic iritis OD • 2) Corneal abrasion OD • 3) Commotio retinae OD • All secondary to blunt eye trauma with unknown object

  20. Assessment? • 4) Trauma possibly caused by child abuse

  21. Plan? • 1-2) Rx: Tobradex qid OD x 1 week • Cyclogel 1% bid OD x 1 week • Ibuprofen 200 mg OTC 3-4 • times a day for one day • Cool compress in evening • 3) RTC 2 days to re-evaluate retina, and again in 1 month to evaluate progress

  22. Plan? • 4) Campus police called, who spoke to mother and patient regarding possible child abuse.

  23. Visit 2: 11/21/02 • CC: Patient presents to OC for follow-up • + mild redness OD • + mild pain OD • + diplopia (present before injury “since the first of the year”)

  24. Visit 2: 11/21/02 • (-) itch • (-) burn • (-) tearing • (-) flashes/floaters • Patient reports that “desk seems farther away than it actually is”

  25. Meds • Tobradex qid OD • Cyclogel 1% bid OD • Ibuprofen 200 mg 3-4 times a day for 2 days (none at time of visit)

  26. Visual Acuities • Unaided distance acuities: • - 20/25- OD, 20/40 OS, 20/25- OU • - With pinhole, 20/20 OD, 20/20 OS • Unaided near acuities: • - 20/60- OD, 20/20 OS, 20/20 OU • - With pinhole, 20/20- OD

  27. Exam findings • PUPILS: • - OD is dilated with Cyclopentolate • - OS is 6-4, RRLA(-)MG • EOM’S: • - FROM, (-) restrictions; pain in all superior gazes OD • CONFRONTATIONS: FTFC OD, OS • CT: 6 p.d. XP; 18 p.d. XP’

  28. SLE • Slightly swollen lids OD • Scratches on superior and inferior lids OD • + 1 conj. injection OD • (-) stain, (-) SPK, clear cornea OD • (-) cell and flare OD • All clear and normal OS

  29. DFE/Gonio OD • (-) retinal edema with only trace “frosting” along retinal vessels from 3 to 10 o’clock • White without pressure • Two small retinal holes at the 8 o’clock position; (-) fluid under holes

  30. DFE/Gonio OD cont’d • (-) angle recession OD • (-) heme OD • 0.3/0.3 CD, pink, distinct margins OD • 2/3 AV OD • +FLR, clear macula OD • Evenly pigmented background OD

  31. Question… • Will Commotio Retinae usually resolve this quickly?

  32. Assessment? • 1) Two small retinal holes OD; stable, asymptomatic • 2) Resolving commotio retinae • 3) Resolved iritis & corneal abrasion • 4) Resolving lid contusions • 5) White without pressure OD • 6) Diplopia due to high exophoria at near

  33. Plan? • 1-2) -RTC 1 month for DFE and full retinal assessment with maximal dilation • -educated patient and language coordinator of s/sx of flashes and floaters • -asked patient and mother to call clinic if flashes/floaters arise

  34. Plan? • 3) -Discontinue Cyclogel 1% bid • OD • -Taper Tobradex: bid x 2 days, then once a day x 2 days, then D/C • -RTC in one month at UEC for DFE and progress evaluation • 4-6) Monitor

  35. Standards for Child Abuse • FIRST... • CALL THE HOTLINE at 1-800-392-3738 • Operated by the Division of Family Services • 24/7, 365 days a year • Operator will take info and respond to child abuse and neglect

  36. Child Abuse • SECOND… • HAVE COMPLETE INFORMATION • Name • Name of the parent(s) • Name of the alleged abuser • Where the child can be located

  37. Child Abuse • You will also be asked: • Is the child in a life-threatening situation right now? • How do you know about the neglect/abuse? • Did you witness the neglect/abuse? • Are there other witnesses and how can they be reached?

  38. Child Abuse • THIRD… • CONSIDER IDENTIFYING YOURSELF • Not mandatory • May help DFS in conducting a more thorough investigation • Can provide valuable info throughout the case as a contact

  39. What if you aren’t sure? • CALL THE LOCAL DFS TO EXPRESS YOUR CONCERNS • Advise you to call/not call the hotline • Give advice that may help the family in crisis • OVER-REPORT!!! Can help families PREVENT abuse!!

  40. Local DFS • St. Louis City: 314-340-5000 • St. Louis County: 314-877-3030 • St. Charles: 636-940-3170

  41. The End • THANK YOU!!!

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