Grand Rounds Blepharoptosis After Fall Patrick Burchell MD

Grand Rounds Blepharoptosis After Fall Patrick Burchell, MD October 12, 2018 Department of Ophthalmology and Visual Sciences

Patient Presentation CC Right Upper Eyelid Ptosis HPI 4 yo female referred for evaluation of RUL ptosis s/p fall 11 months prior. Patient fell while running with unsharpened pencil in hand. Presented to local ED with a small upper eyelid laceration.

HPI • Pencil was intact and did not lodge within the tissue • Underwent EUA with repair of laceration in OR by an outside provider • Constant drooping of RUL, intermittent irritation, erythema, and mucoid drainage OD in months following

History (Hx) Past Ocular Hx: Denies Past Medical Hx: Denies Fam Hx: Non-contributory Meds: None Allergies: NKDA Social Hx: Lives with her parents ROS: + photophobia, redness, mucoid discharge

External Exam OD OS VA CSM Pupils 6→ 3 mm IOP Soft EOM full CVF full No r. APD 6→ 3 mm

Anterior Segment Exam PLE OD OS External/Lids RUL Ptosis; MRD 1: 1 mm WNL Conj/Sclera Pyogenic granuloma of medial palpebral conjunctiva with adjacent cicatrized conjunctiva extending into superior fornix WNL Cornea WNL Ant Chamber Formed Iris WNL Lens WNL

Posterior Segment Exam Fundus OD OS Optic Nerve Pink and sharp WNL Pink and sharp Macula WNL Vessels WNL Periphery WNL

Assessment • 4 yo female with new onset RUL ptosis along with a pyogenic granuloma s/p fall with pencil in hand 11 months prior – Differential Diagnosis: • Traumatic ptosis • Retained foreign body

Plan • Order CT orbits to rule out possible retained foreign body.

CT Orbits Coronal CT without contrast: Soft tissue window Axial CT without contrast: Soft tissue window

Plan • OR for exam under anesthesia with removal of foreign body.

Post Operative Course Post-operative Day # 5 • All previous ocular symptoms subsided • RUL ptosis persisted, but will be addressed surgically in near future

Pediatric Ocular/Orbital Trauma • Estimated 2. 4 million eye injuries in the U. S each year – 35% occur in children < 17 yo • Boys 2: 1 • Most common causes in children: – Projectiles (20%) – Body parts (12%) – Blunt objects (10%) – Sharp objects (9%) – Motor vehicle accidents (4%)

Trauma Evaluation • • • History is key VA, pupils, IOP, EOM External Exam Globe Evaluation Imaging!

Trauma Evaluation • CT orbits is extremely important when septum has been violated

• 25 year retrospective review of 3 oculoplastic surgeons • 268 pediatric patients with acquired blepharoptosis • 34. 7% - Mechanical (infantile hemangioma) • 15. 3% - Traumatic

• 512, 079 eye injuries • Types of injuries • Abrasions or contusions (44. 6%) • Foreign body (8. 9%) • Laceration (4. 9%)

Conclusions • Kids are often difficult to examine, so history is very important • Look for orbital fat as a sign of violation of the septum • Orbital imaging is your friend in trauma situations • Remember wood can hide on CT

Thank You • Dr. Gerber • Dr. Compton • Dr. Timoney

References 1. Rasiah S, Hardy TG, Elder JE, et al. Etiology of pediatric acquired blepharoptosis. Journal of AAPOS 2017; 21: 485487. 2. Abbott J, Shah, P. The epidemiology and etiology of pediatric ocular trauma. Survey of Ophthalmology 2013; 58: 476 -485. 3. Cross JM, Griffin R, Owsley C, Mc. Gwin G. Pediatric eye injuries related to consumer products in the United States. Journal of AAPOS 2008; 12(6): 626 -628. 4. Salvin JH. Systematic approach to pediatric ocular trauma. Current Opinion in Ophthalmology 2007; 18: 366 -372. 5. Sii F, Barry RJ, Abbott J, et al. The UK Paediatric Ocular Trauma Study 2 (POTS 2): demographics and mechanisms of injuries. Clinical Ophthalmology 2018; 12: 105 -111. 6. Al-Otaibi F, Baeesa S. Occult orbitocranial penetrating pencil injury in a child. Case Reports in Surgery 2012; 1 -4.