1. Grand Rounds Blepharoptosis After Fall
Today I would like to present a case of blepharoptosis after a fall.
Patrick Burchell, MD
October 12, 2018

2. Patient Presentation CC HPI Right Upper Eyelid Ptosis
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.
Chief complaint is right upper eyelid ptosis
A 4 yo femal was referred to the oculoplastics clinic for evaluation of RUL ptosis s/p fall 11 months prior. Parents report that the patient fell while running with an unsharpened pencil in hand. The parents took the child to their local ED, where the child was found to have a small upper eyelid laceration.

3. 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
Per the parents, the pencil was intact and did not lodge within the tissue
The child underwent an EUA with repair of the laceration in the OR by an outside provider
Subsequently the patient developed constant drooping of her RUL, intermittent irritation, erythema, and mucoid drainage in the months following the accident

4. 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
- The patient was other wise healthy, no significant past ocular or medical history.

5. External Exam OD OS VA CSM Pupils 6→3mm No rAPD IOP Soft EOM full CVF
- External exam was within normal limits, with no evidence of restriction of any EOM, and no RAPD

6. 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
Cornea
Ant Chamber
Formed
Iris
Lens
On anterior segment exam the child was noted to have RUL ptosis with an MRD 1 of 1 mm
A pyogenic granuloma was noted on the medial palpebral conj along with adjacent cicatrized conjunctiva extending into the superior fornix

7. Posterior Segment Exam
Fundus OD OS
Optic Nerve
Pink and sharp
WNL
Macula
Vessels
Periphery
- Posterior segment exam was unremarkable

8. 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
We have a 4 yo female with new onset of RUL ptosis as well as pyogenic granuloma that began after a fall with a pencil in hand approximately 11 months prior
Our differential diagnosis at this time was really traumatic ptosis vs retained foreign body

9. Plan Order CT orbits to rule out possible retained foreign body.
- Our next step was to order a CT of the orbits to rule out a possible retained foreign body

10. CT Orbits Coronal CT without contrast: Soft tissue window
Upon review of the imaging; a conical shaped foreign body measuring 17 mm x 8 mm with both high and low density components in the superomedial extraconal space was discovered
No associated fractures or abnormalities involving the globe, optic nerve, or EOM were appreciated
Coronal CT without contrast: Soft tissue window
Axial CT without contrast: Soft tissue window

11. Plan OR for exam under anesthesia with removal of foreign body.
The patient was then scheduled for an exam under anesthesia with removal of the foreign body
A superior lid crease incision was made and the superiormedial orbit was explored
A pencil eraser and its metallic ferrule were removed in their entirety under direct visualization
No wood was identified
The wound was copiously irrigated with antibiotic solution and the skin was closed with fast absorbing gut suture

12. Post Operative Course All previous ocular symptoms subsided
Post-operative Day # 5
She had an unremarkable post operative course
All previous ocular symptoms of irritation, photophobia, redness, and mucoid discharged subsided
There was persistence of RUL ptosis, which will be addressed surgically in the near future
All previous ocular symptoms subsided
RUL ptosis persisted, but will be addressed surgically in near future

13. 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%)
- It is estimated that 2.4 million eye injuries occur in the US each year of which 35% occur in children < 17 yo
18% of these injuries are in children < 12 years old
Boys outnumber girls 2:1
Projectiles are the most common cause in children followed by body parts like fingers or fists; blunt objects; sharp objects; and motor vehicle accidents

14. Trauma Evaluation History is key VA, pupils, IOP, EOM External Exam
Globe Evaluation
Imaging!
- When evaluating a child with trauma the history is key especially as to what the mechanism of the injury was
You then want to perform a full ophthalmic exam including VA, pupils, IOP, EOM
On external exam you want to evaluate for any lacerations or possible damage to the canalicular system
The globe should be inspected thoroughly – there are many reports of dart injuries resulting in endophthalmitis as they are easily missed
Imaging is very important and can be very helpful especially in situations where kids are very difficult to examine

15. Trauma Evaluation
CT orbits is extremely important when septum has been violated
All lacerations should be inspected thoroughly to make sure that the orbital septum has not been violated
This is usually evidence by fat prolapse in the peri-ocular wound
- It is very important to evaluate for this because you run the risk of a retained foreign body as in our case

16. 25 year retrospective review of 3 oculoplastic surgeons
268 pediatric patients with acquired blepharoptosis
34.7% - Mechanical (infantile hemangioma)
15.3% - Traumatic
The most common cause of acquired blepharoptosis was Mechanical and in specific infantile hemangioma
The second most common was traumatic

17. Abrasions or contusions (44.6%) Foreign body (8.9%) Laceration (4.9%)
512,079 eye injuries
Types of injuries
Abrasions or contusions (44.6%)
Foreign body (8.9%)
Laceration (4.9%)
- The was a retrospective review that evaluated 512,079 eye injuries in kids that presented to an ED
- Desk supplies came in 5th

18. 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

19. Thank You
Dr. Gerber
Dr. Compton
Dr. Timoney

20. References
Rasiah S, Hardy TG, Elder JE, et al. Etiology of pediatric acquired blepharoptosis. Journal of AAPOS 2017;21:
Abbott J, Shah, P. The epidemiology and etiology of pediatric ocular trauma. Survey of Ophthalmology 2013;58:
Cross JM, Griffin R, Owsley C, McGwin G. Pediatric eye injuries related to consumer products in the United States. Journal of AAPOS 2008;12(6):
Salvin JH. Systematic approach to pediatric ocular trauma. Current Opinion in Ophthalmology 2007;18:
Sii F, Barry RJ, Abbott J, et al. The UK Paediatric Ocular Trauma Study 2 (POTS2): demographics and mechanisms of injuries. Clinical Ophthalmology 2018;12:
Al-Otaibi F, Baeesa S. Occult orbitocranial penetrating pencil injury in a child. Case Reports in Surgery 2012;1-4.